OWCP Makes CQS Information Available via ACSDOL
Web Bill Processing Portal (June 2009)
OWCP Forms
What a Federal Employee Should Do When Injured At Work down load Form CA-10
Form CA -1: A Traumatic Injury is defined as a wound or other condition of the body caused by external force, including stress or strain within a single day or work shift. The injury must be identifiable by time and place of occurrence and member of the body affected. It must be caused by a specific event or incident or series of events or incidents within a single day or work shift.
Traumatic injuries also include damage to or destruction of prosthetic devices or appliances, including eyeglasses, contact lenses, and hearing aids, if they were damaged incidental to a personal injury requiring medical services. (Personal property claims can be made only under the Military Personnel and Civilian Employees’ Claim Act, 31 U.S.C. § 3721.)
For Traumatic Injuries, the employee (or someone acting on his/her behalf) must report the injury by completing a Form CA-1, “Federal Employee’s Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation,” to his/her manager/supervisor. There is a portion of the Form CA-1 that will need to be completed by the manager/supervisor. The manager/supervisor should submit the completed Form CA-1 through appropriate agency channels to insure claim is received by the OWCP District Office as soon as possible, but no later than 10 working days after receipt of Form CA-1 from the employee. The employee must report the injury by completing the Form CA-1 within 30 days of the injury in order to be eligible for Continuation of Pay (COP) entitlements and within three (3) years to meet the FECA time limits of a claim. If the claim is not filed within the 30-day period, and COP is not authorized, employee may file a Form CA-7, “Claim for Compensation”, for loss of wage earnings. However, medical documentation is required within 10 days of the injury or the entitlement to COP will be suspended.
COP is continuation of an employee's regular salary for up to 45 calendar days of wage loss due to disability and/or medical treatment following a traumatic injury. The intent of this provision is to eliminate interruption of the employee's income while OWCP is processing the claim.
When warranted, the manager/supervisor will provide the injured employee a Form CA-16, “Authorization for Examination and/or Treatment.” Form CA-16 may be obtained through your manager /supervisor. The CA-16 is used to provide authorization for treatment. The manager/supervisor should complete the front of the Form CA-16 within 4 hours of the request whenever possible. If there is concern that the facts of the injury are in dispute, the supervisor can check the appropriate box on the Form CA-16 (6.B.2) but still provide the employee with the form. In the event there is no time to complete the Form CA-16, the manager/supervisor may authorize medical treatment by telephone and then forward Form CA-16 to the medical facility within 48 hours. Retroactive issuance of Form CA-16 is not allowed under any other circumstances. However, Form CA-16 may not be used to authorize treatment for Occupational Disease or Illness, without prior approval from OWCP.
The employee has the right to choose his/her initial treating physician. A physician is defined as a surgeon, podiatrist, dentist, clinical psychologist, optometrist, osteopathic, practitioner, and chiropractor within the scope as defined by state law. However, the services of chiropractors may be reimbursed only for treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X-ray to exist. A chiropractor may also provide services in the nature of physical therapy under the direction of a physician. The term “physician” doesn’t include physician assistants or nurse practitioners.
A. Notice of Injury - Form CA-1
When an employee sustains a traumatic injury in the performance of
duty, he or she should file a report on Form CA-1. It may be filed on the
paper form or electronically, depending on the employing agency
participation. The report should be submitted to the supervisor as soon
as possible, but not later than 30 days from the date of injury. If the
employee is incapacitated, this action may be taken by someone acting
on his or her behalf, including a family member, union official, or
representative. (The supervisor may provide such notice as well.) The
paper form must contain the original signature of the person giving
notice. Employing agencies that submit claims electronically must print
a copy of the form and retain the claimant’s or representative’s
signature. The supervisor should:
(1) Review page one of the form for completeness and accuracy,
and assist the employee in correcting any deficiencies found;
(2) Complete and sign page two of the Form CA-1, including a
telephone number in case OWCP staff has questions about the injury.
Also, the appropriate codes should be entered on the form. Include
codes for occupation, type and source of injury, agency identification
and location of duty station. (Appendix B of this publication describes
the type and source of injury codes and their use.)
(3) Sign and return to the employee the receipt attached to the
paper Form CA-1 and give a copy of the entire form to the employee.
Or, if submitted electronically, print and sign the copy of the electronic
form and give it to the employee.
(4) Authorize medical care, if needed, in accordance with
paragraph C below;
(5) Inform the employee of the right to elect continuation of pay
(COP), (discussed in detail in Chapter 5), or annual or sick leave if time
loss will occur;
(6) Advise the employee whether COP will be controverted, and if
so, whether pay will be terminated. The basis for the action must be
explained to the employee. (Controversion is discussed in Chapter 5-3;
the reason for controverting a claim must always be shown on Form CA-
1.)
(7) Advise the employee of his or her responsibility to submit
prima facie medical evidence of disability within ten calendar days or risk
termination of COP.
Form CA -2: An Occupational Disease or Illness is defined as a condition produced in the work environment over a period longer than one (1) workday or shift. It may result from systemic infection, repeated stress or strain, exposure to toxins, poisons or fumes, or other continuing conditions of the work environment. For an Occupational Disease or Illness, the employee (or someone acting on his/her behalf) must report the disease of illness by completing a Form CA-2, “Notice of Occupational Disease and Claim for Compensation.” to his/her manager/supervisor.
Form CA -2a: A Recurrence of disability is defined as a spontaneous return or increase of disability due to a previous injury or occupational disease without intervening cause, or a return or increase due to a consequential injury. (A consequential injury is a new injury, which occurs, as a result of a work related injury). A recurrence of a disability differs from a new injury in that with a recurrence, no event other than the previous accounts for the disability.
When an employee, after returning to work, is again disabled due to a prior injury or occupational disease, the employee completes and submits Form CA-2a, “Notice of Employee’s Recurrence of Disability and Claim for Pay/Compensation,” to their manager/supervisor. If the recurrent disability is related to the original injury, the employee is entitled to medical treatment and compensation.
The employee has the burden of establishing that the current condition is related to previous accepted injury or occupational disease condition, with or without work stoppage. If the employee was entitled to use COP and the 45-days of COP have not been exhausted, he/she may elect to use the remaining days, if the 45-days have not elapsed, since first return to duty; otherwise, the employee may elect to use sick, annual leave or leave without pay.
Form CA -7: Claim for Compensation
Form CA -7b: Leave Buy Back (LBB) Worksheet/Certification and Election
Form CA -16: Authorization for Examination And/Or Treatment
Form CA -20: Attending Physician's Report
Compensation for wage loss cannot be paid unless medical evidence has been submitted supporting disability for work during the period claimed. For claims based on traumatic injury and reported on Form CA-1, the employee should detach Form CA-20, complete items 1-3 on the front, and print the OWCP district office address on the reverse. The form should be promptly referred to the attending physician for early completion. If the claim is for occupational disease, filed on Form CA-2, a medical report as described in the instructions accompanying that form is required in most cases. The employee should bring these requirements to the physician's attention. It may be necessary for the physician to provide a narrative medical report in place of or in addition to Form CA-20 to adequately explain and support the relationship of the disability to the employment.
For payment of a schedule award, the claimant must have a permanent loss or loss of function of one of the members of the body or organs enumerated in the regulations (20 C.F.R. 10.304). The attending physician must affirm that maximum medical improvement of the condition has been reached and should describe the functional loss and the resulting impairment in accordance with the American Medical Association Guides to the Evaluation of Permanent Impairment.
Form CA -35: Evidence Required in Support of a Claim for Occupational Disease
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